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APPLICATION FOR PERMIT %W +�+ 't-AN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. I-IAZELTON AVE, STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is v made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District.Q �v�- job Address cI f � ,t' """ Cit ' Lot Sixe PM Owner's Nam Address �� "� 4 � �" ' � Phone +v �` 0 ' nn 13('V-Seo 60 Contractd� L14 c l G Address p T License No. �� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ +-+ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS +•.+ ❑ Industria} ❑ Open Bottom C1 Manteca — Dia. of Well Excavation _ Dia. of Well Casing ❑ Domestic/Private 0 Grave! Pack ❑ Tracy Type of Casing Specifications F-1 Public ❑ Other' Cl Delta Depth of Grout Seal Type of Grout I I irrigation _Approx. Depth l I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P, State Work Done Well Destruction 0 Weil Diameter Sealing Material (top 501 Depth Fillef Materia! (Below 50') -- �' TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l I DESTRUCTION I I INo septic system permitted it public sewer is available within 200 feet.] Installation will serve: Residence v Commercial�11,,Other tr Number of living units: -_/_` Number of ooms. f- / Character of soil to a depth of 3 feet: __ Water table depth SEPTIC TANK U:V/ Type/Mfg Capacity No-No- Compartments PKG. TREATMENT PLT-❑ t Method of Disposal +.r Distance to nearest: Well 1 � Foundation �_ Prapeny Line A LEACHING LINE No. & Length of lines J Total length/size y FILTER BED ❑ Distance to nearest: Well 00 Foundation Property Line •�Q r� SEEPAGE PITS T Depth Size / Number r r f SUMPS LI Distance to nearest: Well l©- - Foundation rF! Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District- Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant m%call all re ire inspections. Complete drawing on rev ersq si Signed Title: Date:ell f x FOR DEPARTMENT USE ONLY / / +.+ Application Accepted by ` / 7 Data Zf I- Area_` �-2— p�t Grout Inspection by, Date s �9 Final Inspection bi 1 ! La Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P-O. Box 2009, Stk., CA 95201 1r FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMtT_NO. INFO CASH EH 13-24(REV.t i H 51 - F ' EH I4-2e